Pain And Palliation Flashcards
Describe the prescribing principles in analgesia
PO whenever possible Regular dosing Match drug and dose to pain Individualised dose to patient factors Patient centered decisions
Describe the WHO pain ladder
Step 1 - paracetamol and NSAIDs
Step 2 - mild opiates
Step 3 - strong opiates
Step 4 - specialist interventions
Adjuvant drugs
What are examples of adjuvant drugs given in WHO pain ladder
Neuropathic pain - gabapentin, pregabalin, carbamezipine
Corticosteroids, muscle relaxants, anti-spasmodics, bisphosphonates for bone pain
What are some step 4 specialist pain mangement interventions
Nerve block Epidurals Spinal stimulation PCA pump Neurolytic block
What is the MoA, contraindications and adverse effects of ibuprofen
COX2 inhibitor, blocks prostaglandin pathway.
Contraindicated in people with hx of gastric ulcer/bleeding, renal impairment, allergy to NSAIDs
Adverse effects: GI bleeding, renal impairment, hepatotoxicity
Interactions: do not use with anticoagulants
Contraindications of paracetamol
Acute liver failure, severe renal impairment
What are examples of weak opioids
Codeine, dihydrocodeine, tramadol
Mechanism of action of tramadol
Opioid receptor agonist, and some antagonism of serotonin and NE receptors
Contraindications of opioid drugs
Acute respiratory depression, comatose, head injuries, increased ICP
Contraindications of codeine
Risk of paralytic ileus, acute ulcerative colitis
Side effects of opioids
CNS: drowsiness, nausea, vomiting, confusion, respiratory depression, dependence, opioid induced hyperalgesia
Others: constipation, itchiness, hypotension, arrythmias, bronchospasms
What is opioid induced hyperalgesia
Paradoxic adverse effects of opioids causing hypersensitisation to pain
What are signs of opioid toxicity
Resp depression Hallucinations Pin point pupils myoclonic jerks Confusion
When to administer naloxone?
Opioid toxicity: RR <8, hard to rouse, Sats <90%
Why should tramadol not be given with SSRIs
Risk of serotonin syndrome
Contraindications of morphine
Acute abdomen, heart failure due to lung disease, delayed gastric emptying, phaeochromocytoma
What strong opioid can be used in poor renal function
Alfentanyl
What are some considerations in palliative prescribing
Previous opioid use Other drug use, chemotherapy Renal/hepatic impairment Route of administration Nutrition/fluid status
4 common types of drugs prescribed in palliative care
Analgesia - morphine/fentanyl
Antisecretions - hyoscine
Anti-emetic - cyclizine, haloperidol
Sedative - midazolam
How to titrate morphine dose in chronic pain?
Start with suggested dose, and 1/6th to 1/10th 24hour dose for PRN break thru.
If uncontrolled, total up 24hr dose and adjust daily dose, no more than 50% increase in 24 hours
If controlled: convert to 12 hourly MR doses
